Pakistan is no stranger to fighting battles against health emergencies; it has danced an arduous and painfully slow dance with the menace of polio. And now it finds itself, like the rest of the world, navigating uncharted territory with the havoc brought on by the Covid-19 virus.
The war against the polio virus may not be over as yet but the invaluable lessons learnt from the successes of one of the most complex public health programmes carry tremendous potential of being utilised as effective tools to facilitate the development and subsequent implementation of a well-informed Covid detection, containment and vaccination policy.
While the global health community had envisaged the investments in polio eradication to be eventually transitioned to serve other health goals as part of the Polio Eradication and Endgame Strategy Plan, right now may be the most opportune time for that transition of knowledge and infrastructure which can serve as forceful weapons to assist the country in fighting this unpredictable and fast mutating enemy – the Covid-19 virus.
In the early 20th century, polio was one of the most feared diseases crippling thousands of children every year. It was only after the introduction of effective vaccines and concerted efforts by the global polio eradication initiative in 1988 did global incidence of polio decline by 99 percent. Over 2.5 billion children since then have been immunized against polio. This would have been impossible without the cooperation of more than 200 countries and 20 million volunteers, backed by an international investment of more than $11 billion.
Pakistan has had to face its own unique challenges in its fight against polio. Lack of political will, political instability, hard-to-reach and highly migrant populations, poor health infrastructure, vaccine hesitancy and refusals, misconceptions, threats and attacks on polio workers are but some of the myriad of hurdles the country had to surmount to achieve major breakthroughs.
In 2014, when Pakistan reported 306 wild poliovirus (WPV) cases, the highest ever in its recent polio eradication history, the newly elected government of Nawaz Sharif declared polio a national health emergency and launched a reinvigorated polio programme with new strategies and interventions to stem the tide of uncontrolled transmission. The key shifts to accommodate the fundamental paradigm shift included the establishment of Emergency Operation Centres which brought partners together as one team under one roof and with the government leadership working towards a single goal.
Keeping the effort completely apolitical, the government worked with provinces ruled by different political parties, to identify high quality managers as EOC coordinators with unblemished record. Clear management and accountability structures were established, with the highest office of the prime minister providing personal oversight and similar levels of commitment and supervision trickled down to provincial levels, with chief ministers and chief commissioners leading from the front and enabling the programme to make positive shifts at the province, district and down to the union council level – resulting in strengthening performance management, accountability and oversight by the government everywhere, and substantially improving vaccination coverage.
Strong evidence based decision-making and monitoring were put in place to guide the programme to review and respond efficiently and effectively to areas with the greatest needs. The programme continued to apply lessons learnt, innovated, and refined tactics in order to stay the course in its efforts to finish the job of poliovirus interruption and ultimate eradication. These actions not only resulted in the reduction in the incidence of polio cases from 306 in 2014 to only eight in 2017 but also witnessed an improvement in the acceptance of the polio vaccine, reducing refusals to below one percent.
With the onset of the third wave of SARS-CoV-2, more dangerous, infectious and virulent than before, the importance of continuously evaluating and adapting the Covid vaccination plan, operations and communication strategy in light of evolving virus epidemiology cannot be overemphasised. So, what are the lessons from the polio programme that can be immediately applied to help us fight the Covid pandemic better?
Political will and building political consensus: My experience with polio eradication has shown that the basic and fundamental ingredient is political will; not empty rhetoric or hollow and fake promises. Polio eradication in Pakistan was declared a national health emergency in letter and spirit. Delays due to bureaucratic hurdles in approvals were dispensed with for vaccine procurement and distribution, hiring of polio staff, and for filling vacant posts of vaccinators at rural health centers. Polio eradication became a national imperative of former PM Nawaz Sharif who worked above party lines to ensure that the programme enjoyed broad political and popular support. He made a commitment to a polio-free world and encouraged collaboration and work across all provinces and political parties for the sake of our current and future generations.
In sharp contrast, we have seen the current prime minister further divide an already polarized country. Instead of using the Covid pandemic as an opportunity to sit with all political parties to pool resources and ideas to help the country out of the biggest health conundrum/quagmire of the century, he has been reluctant in acting decisively and opposed repeated calls by opposition for stricter SOPs implementation and lockdowns to contain the spread of the virus. Decisions have been based on political considerations rather than professional advice – a practice that needs to be avoided.
National Emergency Action Plan: A joint strategy in the form of a national emergency action plan that brought all provinces, led by different and opposing political parties, and partners together articulating clear common goals, priority areas of focus and pooling resources to reach defined results within the National Emergency operation Centre framework was formulated. This plan ensured buy-in from all provincial governments and allowed the broad political consensus that is a critical component in successfully facing and tackling an emergency situation – at that time, a public health emergency of polio, and today Covid-19
Joint planning and policymaking led to joint responsibility and ownership for a common cause; something we see missing today in the heightened tension between provincial and federal governments around disagreements over many issues – severity of the virus, perception management of the people to keep their threat level high, complete or partial lockdowns and their timing, SOPs implementation, vaccine procurement and distribution, etc
Communications strategy: The development and rollout of a transformed communication strategy for eradication was designed to improve trust in the Pakistan Polio Eradication Programme and in vaccines. Special and localised strategies were devised to engage stakeholders and influencers, dispel misconceptions around vaccine safety and efficacy, and address the root causes for parents and caregivers refusing the vaccine.
The key factors in achieving this included putting the 250,000 frontline polio workers – who were key to reach caregivers in the household – at the centre of the programme communications, and enhancing investments in recruitment, training and supportive supervision of frontline workers. These key shifts led to broad community acceptance and quality programme performance across Pakistan, owned and reinforced by all, giving effect to the broad political commitment across all lines which were key ingredients for success then.
In comparison, we witnessed healthcare workers battling their lives on Covid forefronts without adequate protection, acknowledgement or reward. One would have loved to see hundreds of healthcare heroes decorated with national awards.
To be continued
The writer is a former senator and has served as the PM’s focal person on polio eradication.